This study has explored patterns of early course attrition in one medical course over five intakes. Academic failure is a prime cause of early exit in the first part of the course. Recurrent mental health problems, largely anxiety and depression, feature strongly in later course failures. Few of these students gave any cause for concern during their admission interview.
The number of students affected is relatively small, yet still significant for each one who has made the major life decision to read medicine, then either finds it is not the right choice or has to suffer the consequences of course failure. Our best efforts in admission and selection procedures do not always succeed, for a multitude of possible reasons; academic ability at school may not be sufficiently adaptable to meet the demands of the medical course; unanticipated health or social problems may derail progress, or the realities of clinical medicine may be overwhelming. This study has also illustrated that family pressure has, in a few cases, resulted in students who do not have enough personal motivation to thrive and succeed, and perhaps this also was an undeclared factor in some of the students who changed their minds within the first year or two. Currently the Faculty does not ask such students about their decision to leave in any depth, and therefore our information is lacking in detail. There were clearly many interacting factors that we could not analyse. We believe that the introduction of a structured exit interview will help us to quantify these issues in future.
The majority of medical students will have been high-achievers at school and have equally high expectations of their future abilities. They may find it hard to accept that they are not coping academically, and thus be reluctant to seek or accept help even when it is evident to tutors that they need to do so . The students in this study who were given a second chance, by repeating Year 1, yet still failed, may have lacked key strategic learning skills; successful remediation may require very specific interventions to address any deficiencies , which has resource implications for the Faculty. A study based on individual student appraisal meetings at another UK medical school has suggested that up to 70% of first year students may recognise the need for advice on study skills, but not all will achieve the necessary goals . Our students are asked about academic issues at their regular meetings with personal tutors, but the extent to which study skills are explored and reflected upon may vary between different tutors and not lead to targeted or mandatory interventions.
Medicine requires physical and mental stamina and resilience [10–12], and health issues were often a significant factor in course attrition. Several students who withdrew in the clinical course had clearly been struggling in the face of poor mental health for some years. Medical students may perceive additional difficulties with ill-health because of fears about confidentiality [13–16] . However, looking after one’s own health and well-being is required by the General Medical Council as a pre-requisite for safe medical practice [17, 18].
As yet there is no valid and acceptable way to detect psychologically vulnerable students. Research in Australia has demonstrated the impact of dysfunctional tendencies on academic performance, which may therefore contribute to drop-out . Much attention has been given to the development of valid and robust psychological tests which could be used to screen out candidates with extreme personality characteristics . However, a longitudinal study of students in the UK who sat this test has unfortunately been technically unable to report on any association with drop-outs .
Can anything more be done to reduce attrition? In the case of students who leave within weeks after a change of heart, probably not; they had managed to convince our interview panels of their suitability and motivation.
Similarly, there was no conclusive evidence within our data that those who failed to complete the course were less academically able on course entry. A recent systematic review of the literature has concluded that a poorer pre-admission academic record may sometimes be associated with dropout , but our students almost all arrive with good academic grades. It will be interesting to see whether the UKCAT test, currently used by Nottingham and many other UK medical schools , shows any correlation with course performance or failure. Early evidence is equivocal [23, 24]. Measurable academic ability may however be compromised by deficient study processes or external personal and social circumstances, requiring individual support and mandatory remediation . Although we strive to offer personal academic support at Nottingham, ultimately it is the student’s responsibility to engage. Those who need the most help may be those who decline , and there has to be a line drawn between giving appropriate support and raising expectations too high by ‘failing to fail’ .
In the clinical years, when our students are based in a variety of different clinical settings, some distant from Nottingham, tutor contact may be less easy. We are therefore reviewing the support mechanisms for our clinical students.
In the case of severe or recurrent health issues, especially mental health, there is perhaps a need for the GMC to develop additional guidance to medical schools. Current documents state that health concerns can be addressed within Fitness to Practise procedures but do not provide the practical advice that may be required . Although the medical school may seek the advice of Occupational Health physicians when a student has needed ‘time out’ for health reasons, their assurance that a student is fit to continue their studies may still leave doubt about fitness for an on-going career. A small number appear to lack insight into their future ability to function as a doctor, so earlier but more decisive action may be required.
Limitations of the study
This study has looked at only five cohorts of students at one University, and our data would not necessarily generalise to other medical schools with different entry systems and student profiles. Directly comparable data from other individual UK schools is unavailable, but one study has suggested nearly 5% attrition within the first year alone across all UK medical schools , higher than that at Nottingham, where it is essentially unchanged since 1995–1999 .
Much of the data collected was textual and relied on notes placed in the student files, and of course on what the students themselves disclosed. It is likely that the incidence of problems is higher than shown, and the reasons for withdrawal more complex. However, a similar mixture of reasons was given by students withdrawing from an Australian course in 1978–89, suggesting that there is a degree of generalisability both over time and internationally .
The categorisation of data detailing health or personal issues can be difficult as these issues are idiosyncratic and context-dependent. This categorisation therefore required an element of judgement in some cases. However, the author has no personal knowledge of, or contacts with, any of the students, enabling assessment of data without personal prejudice.
Within our own medical school we have a graduate entry stream, with a group of strugglers and non-completers, whose data may reveal different problems; these mature students may have growing families, mortgages, and quite different expectations and pressures from the average 18-year old undergraduate. This part of the study will be reported separately. It would also be interesting to compare attrition on courses at other medical schools, within different intakes and curricula, especially if they conduct and record routine exit interviews. A recent systematic review has revealed the need for more rigorous studies of dropout at medical school .